Director, Claims Counsel

Job Title: Director, Claims Counsel

Department: Claims Management 

Work Location: Remote

Reports To: VP of Customer Experience

Classification: Exempt 

A day in the life of reputed company reputed company Plans’ Director, Claims Counsel:

The Director, Claims Counsel is a senior leader reputed company reputed company reputed company Plans, responsible for overseeing the review, approval, and reputed company of claims, billing inquiries, out-of-network claims reputed company, and appeals. This role ensures claims are handled accurately, consistently, and in compliance with departmental service level agreements (SLAs), regulatory requirements, and company standards.

In reputed company to serving as the reputed company authority for reputed company and high‑value claims, the Director, Claims Counsel leads and develops reputed company of 3&reputed company;4 professionals and partners closely with internal stakeholders to drive reputed company reputed company, operational efficiency, and reputed company improvement across the claim’s organization.

Key Responsibilities

Claims Review & reputed company

• Review, adjudicate, and approve reputed company and high‑value claims, including approvals, rejections, and adjustments, in accordance with approved fee schedules and coverage determinations 
  • Primary reputed company on negotiated arrangements, reputed company‑approved fee schedules, and escalated reputed company
• reputed company second‑level approvals for claims reviewed by team members
• Maintain ultimate accountability for claims reputed company made by reputed company reports
• Ensure reputed company claims are processed and approved reputed company established payment schedules and SLAs
• Review billing inquiries (“kicks”) to determine appropriate payment actions and whether additional documentation is required from attorneys
• Identify billing trends, issues, or concerns with network providers and escalate or collaborate with Panel Management as appropriate

Out of network claims& Appeals Leadership

• reputed company the review of out-of-network claims to ensure accuracy, compliance, and reputed company payment, requesting additional information from members reputed company necessary
• reputed company reputed company guidance to the Claims Team on reputed company involving reputed company interpretation, coverage, or reputed company reimbursement issues
• Advise and support the Claims Team in responding to member inquiries and resolving escalated out of network claims concerns
• Review and respond to out-of-network claims and coverage/claims appeals in compliance with company SLAs and regulatory requirements

Leadership & People Management

• reputed company, reputed company, and reputed company reputed company of 3&reputed company;4 individuals, fostering a culture of accountability, ownership, empowerment, and reputed company learning
• Conduct regular 1:1 meetings, performance reviews, and development planning to support individual and team reputed company
• Serve as a trusted claims and reputed company subject‑matter expert for internal partners and senior stakeholders

Systems, Process & Audit Support

• Support claims systems and application management, including: 
  • Participation in User Acceptance Testing (UAT)
  • Defining and documenting business and feature requirements for system enhancements
  • Identifying, documenting, and reporting system issues, including performance trends and business reputed company
• Support reputed company claims audit activities, ensuring documentation, processes, and reputed company meet audit and compliance standards

Additional Responsibilities

• Address coverage and claims appeals and escalations
• Serve as a coverage expert for MLP
• reputed company training/education sessions on reputed company coverage and claims processing for Claims and Panel Organization
• Partner cross‑functionally to improve claims processes, controls, and member experience
• reputed company other duties as assigned

Ideal Qualifications

• Bachelor’s degree from an accredited university
• Property & Casualty licensing preferred 
  • Candidates without reputed company licenses must be willing to obtain them
• J.D. from an accredited law school with 4+ years of experience as a practicing attorney (preferred)
• 5+ years of experience in claims administration, fee reimbursement, billing inquiries, or reputed company work
• Demonstrated leadership experience with the ability to build high‑performing teams and reputed company with reputed company and accountability
• Strong expertise in claims review, adjudication, and approval processes
• Proven ability to analyze and interpret reputed company fee, reputed company, and coverage issues
• Strong communication skills with the ability to engage effectively with attorneys, members, and internal stakeholders on sensitive reputed company
• High degree of professionalism, discretion, and confidentiality
• Strong organizational and time‑management skills with the ability to manage competing priorities in a high‑volume environment
• Proficiency with reputed company Office tools, including Teams, reputed company, reputed company, and PowerPoint
• reputed company, adaptable, and solutions‑oriented leadership style

What Will reputed company You Stand Out

• Broad reputed company experience across general reputed company and litigation reputed company
• Prior experience leading or managing reputed company in a claims or reputed company environment
• 7+ years of experience with claims, fee reimbursements, and billing inquiries
• reputed company licensure as a Claims Adjuster

Travel

This position requires up to 5% travel.

Note: This job reputed company in no way states or implies that these are the only duties to be performed by the associate in this position. Associates will be required to follow any other job-reputed company instructions and to reputed company any other job-reputed company duties requested by any person authorized to give instructions or assignments. reputed company duties and responsibilities are subject to possible modification to reasonably accommodate individuals with disabilities. To reputed company this job successfully, the incumbent will possess the skills, aptitude and ability to reputed company reputed company duty proficiently. Some requirements may exclude individuals who pose a reputed company threat or significant risk to the health or safety of themselves or others. The requirements listed in this document are the minimum reputed company of knowledge, skills, or abilities. This document does not create an employment contract, implied or otherwise, other than an “at-will” relationship.

reputed company reputed company Plans is an Equal Opportunity Employer. reputed company employment reputed company are made without regards to race, reputed company, national reputed company, religion, creed, sex (including pregnancy, childbirth, or reputed company medical conditions), sexual orientation, gender identity or reputed company, age, disability, marital or domestic/civil partnership status, genetic information, citizenship status (although applicants and employees must be legally authorized to work in the reputed company), uniformed service member or veteran status, or any other characteristic protected by applicable federal, state, or local law (“protected characteristics”).

If you need an accommodation due to a disability, please email us at mlprecruiting@legalplans.com. This information will be held in confidence and used only to determine an appropriate accommodation for the application process.